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Surgical Procedure for Posterior Cervical Spine

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1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Celebrex/Naprosyn/other anticoagulants and anti-inflammatory drugs for at least 2 weeks

2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist

3. Patient placed prone with Mayfield pins on Jackson Table with all pressure points padded

4. Neuromonitoring is needed

5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed

6. Make an incision down the midline of back, over the vertebrae where laminectomy is to be performed

7. Perform subperiosteal dissection of muscles bilaterally to expose the spinous process and paraspinal muscles

8. Dissect tissue planes along spinous process and laminae using rongeurs

9. Move paraspinal muscles laterally to expose the laminae

10. Once the bone is exposed, it is best to localize and verify the correct vertebra via X-ray or fluoroscopic imaging and confirming with at least two people in the room

11. Perform the laminectomy over segments needed based on preoperative imaging of levels that are compressed due to tumor:

a. Using Leksell rongeurs and hand-held high-speed drill, remove the bony spinous process and bilateral lamina as indicated for specific procedure

b. Remove the thick ligamentum flavum with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak

c. Perform appropriate foraminotomy with Kerrison rongeurs as needed for appropriate decompression of nerve roots

d. Identify location of tumor and resect tumor as needed within the spinal canal:

i. Use operative microscope and open the spinal cord dura midline with 11 blade and tack up the dural leaflets with suture

ii. If tumor is intradural and extramedullary, the tumor can then be resected carefully with microdissection technique without cord injury (neuromonitoring needed in these cases)

iii. If tumor is intradural and intramedullary, with microdissection technique the cord must be entered midline and the tumor must be identified and resected starting centrally first, then around the edges (neuromonitoring needed in these cases)

12. After appropriate tumor resection, there may be need for additional stabilization to prevent kyphosis if the resection caused multiple segment decompression. Therefore, instrumentation with lateral mass screws can be placed over the segments involved with rods bilaterally and fusion/arthrodesis along these segments

13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative drains that can be removed after 2 to 3 days

Neurosurgery Outlines

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